Brian Sinclair's 34-hour ER wait

Malo said the request didn't seem urgent. He said he finished some triage paperwork before he looked into the waiting area.

"There was nothing in the waiting room, no group of people around an individual," he said. "There wasn't any commotion."

Minutes later, Sinclair's lifeless body was discovered by a security guard and wheeled into the resuscitation room. He was pronounced dead almost immediately.

It was only after Sinclair was found lifeless that Malo realized the 45-year-old had been in the ER waiting room for two days.

Malo said he had checked during his previous shift to see if Sinclair had a hospital admissions bracelet, but didn't see one. At the time, Sinclair had been sitting in his wheelchair in the waiting room for about 15 hours.

Sinclair was asleep at the time and Malo said it didn't strike him as usual. People regularly came in seeking shelter, while others had been discharged and were waiting for a ride, Malo said. He told his lawyer he gave Sinclair's lack of a bracelet about "10 seconds" of consideration - "if that."

"There were always more people in the waiting room than there were charts."It never occurred to him that Sinclair had been waiting for hours without being formally triaged or examined, Malo said.

"People don't tend to sit for three, four, five hours and not approach somebody," he testified. "People are usually pretty livid by the time four hours rolls around and they haven't been called."

Video surveillance shown by Vilko Zbogar, the Sinclair family lawyer, shows Malo walked past Sinclair less than an hour before he was discovered dead. Malo said he didn't notice Sinclair.

The inquest is scheduled to sit this week before resuming again in February, when it is expected to examine the broader issue of hospital wait times and backlogs.